Tech Support Request Form Templates - PDF

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                   Tech-Check-Tech Program

 Developed and Approved by the Minnesota Society of Health-
System Pharmacists. Approved by the Minnesota State Board of
                    Pharmacy July 2003.
                                Table of Contents
I.     Overview

II.    History of the Tech-Check-Tech program

III.   Tech-Check-Tech Requirements (MN State Board of Pharmacy & MSHP Approved
       Program)

       A.   Hospital Requirements
       B.   Technician Eligibility
       C.   Training
       D.   Process
       E.   Validation and QA Process
            1. Initial Validation process and Re-validation process
            2. Required QA process

IV.    Tech-Check-Tech Training Module

       A.   Definitions
       B.   Program Overview
       C.   Elements of Checking
       D.   Accuracy and Medications Errors
       E.   Process Orientation
       F.   Sample Tests

V.     Form Templates

       A.   Sample Variance Request Letter
       B.   Training Check List
       C.   Initial Validation Form
       D.   Audit Tool
       E.   QA Tracking Form
       F.   Yearly Program Summary

VI.    References

       A. Tech-Check Tech
       B. Safety References




                                             2
I.   Overview

     A. Description
        This packet is a compilation of materials for the Tech-Check-Tech (T-C-T) Program.
        The program was designed by the Minnesota Society of Health-System Pharmacists
        (MSHP) and approved by the Minnesota State Board of Pharmacy (MN BOP). These
        materials describe the program and requirements and provide a sample training
        packet.

     B. Audience
        This packet is intended to provide hospital inpatient pharmacies the necessary
        information needed to implement the T-C-T program.

     C. Board Variance
        A variance approval from the Minnesota Board of Pharmacy must be obtained before
        the site can begin implementation of the T-C-T program.

     D. Goal of Tech-Check-Check
        The goal of this program is to utilize well-trained pharmacy technicians to perform
        daily non-judgmental pharmacy functions, and allow the pharmacist to perform more
        clinical and patient counseling services.

     E. Definitions
        Automated Medication Distribution Systems (AMDS)
           A secured device that stores and distributes applicable medications upon request
           and requires an electronic personnel identification system

        Error in AMDS
           Any occurrence of a wrong drug, dose, quantity, dosage form or an expired date
           in a line item (each line counts as one error).

        Error in Unit of use cart
           Any occurrence of a wrong drug, dose, quantity, dosage form or an expired date.
           Each dose counts as one error.

        Hospital Coordinator
           Person responsible for adherence to the T-C-T program requirements.

        Line Item
           A checking unit for AMDS restocking (example: a single product of a specific
           drug and dose, regardless of quantity).

        Technician Checker
           An individual who has completed the T-C-T validation process and is currently
           authorized to check another technician’s work.


                                             3
Tech-Check-Tech (T-C-T)
   A program utilizing specifically trained and qualified pharmacy technicians to
   check AMDS medications and unit dose batches filled by another technician.

T-C-T Site Coordinator
   The pharmacist responsible for meeting the T-C-T program requirements listed in
   this document.

Unit Dose
   A physical quantity of drug product designed to be administered to a patient
   specifically labeled as to identify the drug name, strength, dosage amount and
   volume, if applicable. Unit of use can be obtained from the manufacturer of the
   drug, repackaged from an external re-packager, or repackaged on-site through a
   batch repackaging process that includes a registered pharmacist as a check. Unit
   dose examples include oral solids individually packaged by a manufacturer or re-
   packaged, oral liquids drawn up in a labeled oral syringe, injectable products, and
   pre-mixed IV products.

   Unit dose cassettes or envelopes are modes of delivering a hospital inpatient’s
   medication doses for a predefined period of time, usually 24 hours. Cassette
   drawers or envelopes are labeled with the patient’s name and location and are
   typically delivered to the patient care area by a pharmacy technician.




                                     4
II. History of the Tech-Check-Tech program


  History
  The Tech-Check-Tech (T-C-T) program was designed by the Minnesota Society of Health-
  System Pharmacists in the late 1980's.

  Prior to 1978 there were no specific MN Board of Pharmacy laws stating that pharmacists
  were required to check unit dose carts or that technicians were prohibited from doing so.
  There were several hospitals around the country and in MN that had technicians routinely
  checking patient unit-dose carts. In 1978, the Minnesota Board of Pharmacy (MN BOP)
  established a law that stated that this was a pharmacist’s function.

  In 1989, MSHP worked in conjunction with the MN BOP to develop guidelines for the use of
  technicians in the non-judgmental task of checking unit-dose batches. These guidelines
  established strict training and quality assurance (QA) parameters governing the use of “Tech-
  Check-Tech” (T-C-T) in hospital pharmacies and to assure QA while verifying the accuracy
  of the technicians and the process. The guidelines also limited T-C-T to hospitals by
  requiring that “The drug distribution system must be structured such that a minimum of one
  additional check by an independent party must be completed prior to the administration of
  the T-C-T checked medications to the patient. (E.g. nursing).” The intent of this program is
  to free pharmacists from non-judgmental distributive functions so that the unique skills of
  pharmacists can be better utilized to improve the medication related patient outcomes in
  hospitalized patients.

  In 2002, the MN BOP asked MSHP to revise the T-C-T guidelines to incorporate processes
  related to automation. . The MSHP group also reviewed the QA and validation processes of
  the original guidelines, as these guidelines had not been changed since the initial three-year
  study ended in 1991. The 2003 revisions modify the original QA measures to a scope that
  allows smaller hospitals to utilize this program. These revisions still validate the technician’s
  ability to perform the function, but establish a more practical system to implement and
  monitor this program.

  Hospital sites that utilize the T-C-T program have patients that continue to receive
  medications with a high accuracy rate and pharmacist labor has been utilized to further
  improve patient safety by focusing on assessing the accuracy and appropriateness of the
  medications ordered and educating staff and patients.




                                               5
III. Tech-Check-Tech Requirements (Minnesota State Board of Pharmacy
     and MSHP Program)

  A. Hospital Requirements

     To participate in the Tech-Check-Tech program, the hospital pharmacy must meet the
     following requirements:
     1. The participating hospital must work with the appropriately titled hospital specific
         committees and/or groups for acceptance and approval before the T-C-T program can
         be implemented. These groups should have representation of hospital administration,
         nursing, pharmacy, risk management, patient safety and care. Some examples are
         P&T committee, Patient Safety committee, Nursing and Pharmacy committee, etc.
     2. The participating hospital must have one pharmacist designated as the responsible
         person for meeting the T-C-T program requirements listed in this document. This
         person shall be called the T-C-T Site Coordinator.
     3. The participating hospital must have a drug distribution system that is structured to
         allow for one additional check of the dispensed medications by a licensed nurse (or
         other licensed health care professional with authority to administer medications) after
         the delivery of checked medications.
     4. The participating hospital must have adequate staffing to support a consistent
         utilization of the T-C-T program.
     5. The participating hospital should develop a policy and procedures for the T-C-T
         program and have them available for board inspectors. The hospital should define a
         list of high-risk medications that are exceptions to T-C-T and include this list in the
         policy and procedures.
     6. The T-C-T program is a tool to allow the re-direction of pharmacists from a
         distributive task to cognitive tasks. It is designed to allow pharmacists to further
         improve patient safety by focusing on assessing the accuracy and appropriateness of
         the medications ordered and educating staff and patients. The program must not be
         used as a mechanism to reduce pharmacist staff.
     7. The participating hospital must include T-C-T as a technician duty and must have the
         pharmacists-in-charge submit it to the Minnesota Board of Pharmacy.
     8. The participating hospital must obtain a T-C-T variance from the Minnesota Board of
         Pharmacy.
     9. The drug description on the batch fill document or label must contain the same
         description as the one on the labeling of the unit of use package.
     10. A pharmacist must perform a daily review of patient profile containing pertinent
         clinical information about the patient (i.e. Allergies, current medication, etc.).
     11. A pharmacist must check the preparation of all products extemporaneously packaged
         and IV admixtures prepared in the pharmacy.
     11. The participating hospital must incorporate the T-C-T program into the department’s
         general orientation process.
     12. The Pharmacist-in-Charge must review all records on an annual basis to assure
         compliance with this document.




                                              6
B. Technician Eligibility

   In order for a technician to participate in the T-C-T program, a technician must fall into
   one of the following categories:

   1. A registered intern (in pharmacy school) with 6 months experience in unit dose
      filling.
   2. A technician working full or part time with one-year equivalent experience in unit
      dose filling.

C. Training

   The participating hospital must use this MSHP approved T-C-T module to formalize
      didactic training and quality control.
      • All technicians are required to undergo specific training to participate in the
          program. The goal of this training process is to have the technician checker
          become validated and accomplish all the necessary didactic objectives. The
          training process must include the following:

           1.      Didactic lecture (or equivalent training with a self-learning packet)
           2.      Practical sessions (one-on-one training) that consists of observation of a
                   pharmacist checking a unit dose medication batch and/or cart
           3.      Validation
               • Initial validation
               • On-going QA audits performed quarterly for the first year then once every
                   six months
           *If at any time a T-C-T technician loses his/her validation, that individual must be
           reassigned to another task until he/she is retrained and revalidated.

       •   The practical session will start with the trainee observing a technician checker
           performing either the unit dose batch or the AMDS stocking check process. Then
           the trainee performs the initial check with a registered pharmacist verifying all
           doses. During the final stages of the practical session, the technician will
           complete the validation process. The training process will include introducing
           artificial errors (see validation), into a live or simulated environment, to monitor
           the ability of the technician to catch errors. Artificial errors introduced into the
           live environment, which are not corrected by the technician, shall be removed. A
           pharmacist must maintain initial validation and documentation for each validated
           T-C-T technician as well as notify a technician checker of any errors found during
           audits.

       •   Development of individualized training programs will be the responsibility of
           each site in order to tailor the program to the patient population and medication
           distribution system of the institution. Assessment questions should be tailored to
           the site and be changed periodically as appropriate. It will be the responsibility of
           the hospital coordinator to ensure that all training is completed and documented.
           A summary report of each pharmacy technician trained as a technician checker

                                             7
          will be kept on file by the hospital coordinator. Note: An organization may
          choose to place a copy of the training documentation in the employee’s personnel
          file.


D. Process

   1. A pharmacy technician fills the medication for the unit dose or Automated
      Medication Distribution System restocking batch.

   2. A validated technician checker may check the accuracy of unit dose batches or
      automated medication distribution system restocks. The technician checker reviews
      the medications for the correct drug, dose, dosage form, quantity and reviews the
      expiration date.

   3. If a filling error is found, the technician checker records the error and the product is
      given back to the technician who originally filled it (if available) or another
      technician. The technician then corrects the error and technician checker checks the
      correction. A pharmacist or another validated technician checker must check any dose
      corrected/filled by a technician checker.

   4. If a validated checker is not available, then all doses must be checked by a
      pharmacist.

   5. This process continues until all doses have been checked.


E. Validation and QA Process

   1. Initial Validation (and re-validation if needed)

      Unit of Use Batch: For initial validation, the technician checker must obtain a 99.8%
      accuracy rate in 1500 consecutive doses (divided in at least 5 separate audits). The
      audit process will consist of a registered pharmacist checking the accuracy of a unit of
      use medication after the technician has checked them. Any errors determined to be
      due to the improper checking by the technician checker will be documented and
      discussed with the technician. In each audit, the pharmacist will artificially introduce
      at least three errors. The pharmacist coordinating the audit will keep a record of the
      introduced errors to ensure that all are removed prior to distribution. All audit results
      will be documented by the pharmacist and kept in the quality assurance file. Errors
      will include an occurrence of a wrong drug, dose, quantity, dosage form, or an
      expired medication. Each dose will count as one error. If the technician checker
      misses more than three errors in 1500 doses, they fail the validation.

      AMDS: For initial validation, the technician checker must obtain a 99.8% accuracy
      rate in 500 total line items (divided in at least 5 separate audits). The audit process
      will consist of a registered pharmacist checking the accuracy of the AMDS
      medications after the technician has checked them. Any errors determined to be due
                                            8
   to the improper checking by the technician checker will be documented and discussed
   with the technician. In each audit, the pharmacist will artificially introduce at least
   three errors. The pharmacist coordinating the audit will keep a record of the
   introduced errors to ensure that all are removed prior to distribution. All audit results
   will be documented by the pharmacist and kept in the quality assurance file. Errors
   will include an occurrence of a wrong drug, dose, quantity, dosage form or an expired
   medication. Each dose will count as one error. If the technician checker misses more
   than one error in 500 doses, they fail the validation.

2. Quality Assurance Process

   1. The hospital coordinator shall maintain documentation of the quality assurance
      checks (audits). Audits should be conducted in the same manner as in the initial
      validation process. The audits should occur at random and unannounced times.
      The audit sample should be at least 300 doses for the unit of use batch and 100
      line items for the AMDS batch. To maintain validation, no more than one error
      can be made. The audit reports should include each specific error encountered,
      the total number of errors, the total number of doses or line items checked and the
      percent error rate. Once the technician has successfully completed three
      consecutive monthly audits, specific audits for that technician may be reduced to
      quarterly for a period of one year. After a year, audits can be reduced to semi-
      annually. If a technician does not perform the T-C-T duties for more than six
      months, that technician must be revalidated.

  3. If a validated technician checker fails any of the audits, the audit should be
     repeated in the same month. If the technician fails the re-audit, they should be
     reassigned to another duty and must be revalidated prior to checking any more
     doses.




                                         9
IV.   Tech-Check-Tech Training Module
      A. Purpose

         The purpose of the training module is to provide a template of the information
         necessary to meet the required didactic, process orientation training and quality
         control necessary to participate in the Tech-Check-Tech program. This information is
         intended to be combined with one-on-one training in the automated batch, cart fill,
         and pre-made IV checking process.

      B. Program Overview

         Train technician on the Tech-Check-Tech Requirements and Program (Section III Of
         this packet)

      C. Training - Checking

         Upon completion of this portion of training, the pharmacy technician will be able to:

         •   Identify the information required on the label of extemporaneous products
             packaged by the pharmacy.
         •   Differentiate between the packaging, labeling, and product characteristics for
             various oral, injectable, and intravenous medications.
         •   Identify expired or contaminated products.
         •   List the main product characteristics that need to be checked for each drug
             packaged by the pharmacy.
         •   Identify products requiring special handling or special storage conditions.
         •   Identify the generic names associated with common brand names through the use
             of common references.
         •   State the appropriate size of common bulk items to be dispensed.
         •   Describe how AMDS’s work and their associated risks and limitations (where
             applicable).

         1. Therapeutic Drug Classifications (ASHP Formulary Service)
               a. Antihistamines
                  These drugs provide symptomatic relief of allergic symptoms and
                  common cold symptoms. They can be used as a sedative, antiemetic, or
                  for motion sickness. These drugs antagonize histamine.

                b. Anti-Infective drugs
                   These drugs will kill or stop the growth of infective organisms in the body.
                   This group includes anti-viral, antibacterial, and anti-fungal agents.

                c. Antineoplastic Drugs
                   Use of these types of drugs is known as chemotherapy. They are used in
                   cancer treatment, often in conjunction with surgery, radiation therapy, or
                   immunotherapy. They affect cell growth by several different mechanisms.
                                             10
d. Autonomic Drugs
   1. Parasympathomimetic (cholinergic): These drugs increase muscle tone
      of the smooth muscles of the bladder and gastrointestinal tract. They
      are used for urinary retention and to increase gastric motility.

   2. Parasympatholytic (cholinergic blockers): These drugs inhibit motility
      of the gastrointestinal tract and urinary tract. They also decrease
      secretions of the body (saliva, pancreatic, gastric). These drugs are
      commonly used before surgery.

   3. Sympathomimetic (adrenergic): These drugs can be bronchodilators by
      relaxing bronchial smooth muscle by stimulation of beta-2 adrenergic
      receptors. These drugs can cause cardiac stimulation (increase the
      force of contraction) by acting on beta-1 adrenergic receptors. They
      can also cause vasoconstriction by acting on alpha-receptors (nasal
      decongestants) and vasodilatation in skeletal muscle.

   4. Sympatholytic (adrenergic blockers): These drugs block alpha-
      adrenergic action. They cause direct stimulation of smooth muscle
      (vasoconstriction) and vasodilatation by direct relaxation of vascular
      muscle.

   5. Skeletal Muscle Relaxants: These drugs are generally central nervous
      system (CNS) depressants, which have sedation and skeletal muscle
      relaxant effects.

e. Blood Formation and Coagulation Drugs

   1. Antianemia: Iron is needed by our body in hemoglobin so we can
      utilize oxygen in our blood.

   2. Anticoagulants: Warfarin prevents harmful clot formation in blood
      vessels by decreasing the activity of certain clotting factors. Heparin
      is used when an immediate effect is required. It can be used for
      treatment or prevention of clots. Protamine is a heparin antagonist. It
      neutralizes heparin activity by binding to it.

f. Cardiovascular Drugs

   1. Cardiac Drugs: These drugs have several actions, which affect the
      heart. Some are antiarrhythmic drugs. They are used in life
      threatening arrhythmias, such as suppressing ventricular or arterial
      fibrillation, flutter, or tachycardia. Other drugs increase the force and
      speed of the contraction of the heart. They help in congestive heart
      failure. Some drugs block beta-adrenergic receptors in the heart (beta-
      blockers slow down heart rate). They also reduce blood pressure and
      are useful in angina pectoris, cardiac arrhythmias and migraine
      headaches.
                            11
          2. Antilipemic Agents: These drugs are used to decrease elevated serum
             cholesterol and triglyceride levels.

          3. Hypotensive Drugs: These drugs are used in the treatment of
             hypertension. Diuretics are usually used first, and then other types of
             medications are added if necessary. Some are vasodilators, others
             affect the autonomic system, and some are beta-blockers.

          4. Vasodilating Drugs: These drugs are used as coronary vasodilator to
             treat angina pectoris. Some are used for long-term prophylactic
             management and others for acute relief.

       g. Central Nervous System Drugs

          1. Analgesics and Antipyretics: This large group of drugs kills pain and
             decreases fever in the body. Narcotics are also in this category.
             Narcotics analgesics may produce physical dependence. Nonsteroidal
             anti-inflammatory agents represent a large newer group of painkillers.

          2. Anticonvulsants: These drugs are used to reduce the frequency and/or
             severity of seizures in epilepsy.

          3. Psychotherapeutic Drugs: Antidepressants are used in endogenous
             depression and other depressive illnesses. Tranquilizers are used in
             acute and chronic psychoses, including schizophrenia. Some have
             other uses in hiccups and as antiemetics. Hydroxyzine is used to
             relieve anxiety, control emesis, and reduce narcotic requirements
             following surgery.

          4. Sedatives and Hypnotics: These drugs are used to treat insomnia,
             relieve anxiety, and provide routine sedation. They cause CNS
             depression. Barbiturates can cause physical and psychological
             dependence. Benzodiazepines are used for anxiety, insomnia, and as
             anticonvulsants and skeletal muscle relaxants.

2. Drug Classifications

   Controlled substances
      • CI
      • CII
      • CIII
      • CIV
      • CV
   Non-Controlled medications

3. Generic vs. Brand names


                                   12
   Identify the generic names associated with common brand names through the use
   of common references.

   During the drug development process, a medication is given a generic and
   chemical name. Once the FDA approves the drug, the manufacturer proposes a
   brand name for their form of the drug. During the patent life of the drug, no
   generic forms are made; therefore, ordering the drug by brand name is the same as
   ordering it by generic name. In general, generic forms of medications are used
   whenever possible. Therefore, drugs should be referred to whenever possible by
   the generic name. CMARs, cart fill lists and AMDS fills should always list the
   generic name of the drug.

   Generic and brand names can be found in common references. Common
   references may include:
       Micromedex
       American Hospital Formulary Service
       Pediatric dosage handbook
       Drug facts and Comparisons

   Identify common drugs and their brand names.

4. Special handling or storage conditions

   Some products may require special handling or storage conditions like:
   protect from light; bagged separately when in refrigerator; needs refrigeration etc.

   Identify products requiring special handling or storage conditions.

5. Product Characteristics

   IV products: colorless or lightly colored clear solution (in general); exceptions to
   this include Primaxin and Rifampin

   Oral products: can be colorless or densely colored; suspensions are cloudy and
   may tend to separate out to form more than one layer.
   ♦ Example: furosemide (Lasix) - oral solution is yellow/orange and IV
      preparation is a clear solution
   ♦ Some drugs (suspensions) may separate out (precipitate) and cannot be re-
      suspended

   Identify expired or contaminated products.
   ♦ Expiration dates must be checked on each dose of medication. If packaged
      (unit dose) from the manufacturer, this date must be on that packaging.

   ♦ Some products have special stability characteristics or are prone to
     contamination because of packaging


                                    13
   Identify the product characteristics that need to be checked for each medication
   dispensed by the pharmacy:
   ♦ Right Dose
   ♦ Right strength
   ♦ Right number of unit doses
   ♦ Right drug
   ♦ Right dosage form
   ♦ Right packaging
   ♦ Valid expiration date

6. Dosage Forms

   Some medications have unique dose forms. This affects how the drug can be
   given (e.g. whether or not it can be crushed or split).
   Examples include:
   • Nifedipine (Procardia XL) is a matrix tablet that slowly releases the
       medications from a "web-like" structure through a special hole in the tablet
       coating into the GI tract.
   • Valproic acid (Depakote Sprinkles) are small beads that slowly release the
       drug in the small intestine; they must not be chewed but can be sprinkled on
       soft food and swallowed.
   In caring for children and adults with special needs, we often must use/create
   dosage forms that are unique to our patient population.
   Examples include IV dilutions and oral liquid medications not available from the
   manufacturer

   Identify medications with various dosage forms.

7. Expiration Dates

   Expiration dates should be visible on each individual dose. Items that are
   normally stored in the refrigerator should be marked with the appropriate
   expiration for room temperature. All outdated medications should be considered
   an error in the cart fill or ADM batch fill.

   Identify examples of commonly missed expiration dates.

8. Labels
   Information required on the label of extemporaneous products (including drawn-
   up doses for cart fill) dispensed by the pharmacy (for inpatient use) includes:
   ♦ Generic/Trade Name of Drug
   ♦ Strength of Drug
   ♦ Special Instructions
   ♦ Dose
   ♦ Expiration
   ♦ Manufacturer Lot number
   ♦ Hospital name
                                   14
          Various dosage forms require specific packaging and storage because of the
          stability or other characteristics of the drug and should be noted on the label.

          Identify examples of correct product labeling.

D. Training - Accuracy and Medication Errors

   Upon completion of this portion of training, the pharmacy technician will be able to:

   •   Understand the potential impact of the variety of medication errors by reviewing a
       sample of past errors as reported in nationally distributed periodicals, such as
       Hospital Pharmacy and ISMP Medication Safety Alert newsletters as well as those
       experienced at the participating hospital.
   •   Recognize and identify various dosage forms.
   •   Describe the training, validation, and audit process for technicians participating in the
       T-C-T project, including accuracy requirements.
   •   Describe the use of the pharmacy and nursing profile systems (including the
       Medication Administration Record if used as a checking document).

   1. Common Workplace Errors

       Understand the potential impact of medication errors by reviewing past errors as
       reported in Hospital Pharmacy as well as ISMP.

       Medication errors are episodes of a drug misadventure that should be preventable
       through effective system controls involving pharmacists, physicians, other
       prescribers, nurses and others. It is the responsibility of all staff to prevent
       medication errors through accurate job performance.




                                            15
2. Look-a-like Sound-a-like medications

       Identify look-a-like sound-a-like medications.
       •   Ampicillin / Amoxicillin
       •   Nifedipine / Nicardipine
       •   Timentin / Ticar
       •   Potassium Chloride / Potassium Gluconate
       •   Dopamine / Dobutamine

3. Route of Administration

       Identify common errors with routes of administration.

4. Dilution Errors

       Many medications have more than one concentration available. This may result in
       an overdose or underdose of medication.
       Identify possible errors with multiple concentrations.

5. Abbreviations

   Recognize and identify various abbreviations:

   •   Common medical abbreviations and symbols used in Pharmacy:
       MS = morphine sulfate                 Na = sodium
       K = potassium                         Ca = calcium
       Mg = magnesium                        Cl = chloride
       SO4 = sulfate                         PO4 = phosphate
       HCO3 = bicarbonate                    D5W = 5% dextrose (in water)
       NS = normal saline                    LR = lactated ringers

   •   Common abbreviations related to drug strength:
       g = grams (also abbreviated incorrectly as G or gm)
       mg = milligrams (1/1000 of a gram)
       mcg = micrograms (1/1000 of a milligram)
       meq = milliequivalents
       U = improper abbreviation for units
       Gr = grains, an apothecary volume measure = 60 mg
       Kg = kilograms = 1000g = 2.2 pounds

   •   Common abbreviations related to volume:
       L = liter (1000 ml)           ml = milliliter (often written as cc)
       Gtt = drop (not drip)         dram = 5ml = 1 teaspoon
       Oz = ounce = 30 ml            ss = ½ (ss oz = ½ oz)
                                        16
•   Common abbreviations related to route:
    po = oral
    IM = intramuscular (a “shot”)
    SQ = SC = SubQ = subcutaneous (under the skin)
    IV = intravenous (into the vein)
    IT = intrathecal (into the spinal fluid)
    Pr = rectal

    Au = both ears            ou = both eyes
    Ad = right ear            od = right eye
    As = left ear             os = left eye

    GT1 = via gastrostomy tube
    NG = via nasogastric tube
    NJ = via nasojejunal tube
    JT = via jejunostomy tube

    The difference between the above tubes is based on their point of entry and at the
    point in which the end is located. The nasojejunal and nasogastric tubes are
    temporary tubes that are inserted through your nose. The gastrostomy and
    jejunostomy tubes are permanent tubes that are implanted (surgically) through the
    skin. GTs and NGs continue down into the stomach and end there. JTs and NJs
    end in your upper small intestine (jejunum). Some medications cannot be given
    through some of these types of tubes because of how they affect the body. For
    example, sucralfate (Carafate) is a drug that coats the lining of the stomach to
    prevent ulcer formation; it does not make sense to give this drug through a JT or
    NJ because it will bypass the stomach.

•   Common abbreviations in Frequency:
    q = every or each                qd = every day
    qod = every other day            bid = twice a day
    tid = three times a day          qid = four times a day
    h = hr = hour                    q2h = every 2 hours
    prn = as needed                  ac = before meals
    pc = after meals

    The following are usually site specific. There may be several different meanings
    for each.

    STAT                             Demand
    ASAP                             PRN
    ONE                              IRR




                                       17
E. Training - Calculations

   Upon completion of this portion of training, the pharmacy technician will be able to:

   •   Demonstrate an understanding and a working knowledge of the basic mathematical
       principles involved in pharmacy calculations, including: Fractions, Percentages,
       Proportions, Significant figures
   •   Make mathematical conversions between and within the Metric, Avoirdupois, and
       Apothecary systems.
   •   Fraction: a way of describing a portion of a whole (e.g. 1/2 or 3/8)
   •   Percentages: a way of describing a portion out of a hundred (e.g. 50%, 72%).
   •   Proportions: the relation of one part to another or to the whole - often described by a
       fraction or percentage (e.g.1:1000 vs. 1:10000).

   1. Practice calculations

       (Sample exam – the hospital coordinator should change the questions and examples
       on a periodic basis)

       Please complete the following exercises. The answers are included for your
       education. (Questions taken from the Pharmacy Certified Technician Calculations
       Workbook) – should reference this like a regular reference (and really should have
       permission)

       a. Section 1
          1. 4 mg = ________________g
          2. 2 g =    ________________mg
          3. 4000 g = ________________kg
          4. 10 mg = ________________g
          5. 20 cc = ________________ml
          6. 0.75 L = ________________ml
          7. 0.4 L = ________________cc
          8. 600 cc = ________________L
          9. 3 ml = ________________L
          10. 30 ml = ________________cc

       b. Section 2

          Calculate the following dosages. Round your answer to the nearest tenth.

          1. Acetaminophen (Tylenol) elixir 160 mg/5 ml
             Dose: 320mg
             How many ml?

          2. Albuterol liquid 2 mg/5 ml
             Dose: 6 mg
             How many ml?

                                            18
  3. Furosemide 10 mg/ml
     Vial size: 10 ml
     Total vial strength?

  4. Dexamethasone 40 mg/10 ml
     Concentration per ml?

  5. Lidocaine 1% injection 10ml vial
     What is concentration in mg/ml?

  6. Midazolam 2 mg/2 ml
     What is the concentration per ml?

  7. Bumetanide injection 0.25 mg/ml
     Dose: 2 mg
     How many ml?

  8. Carbamazepine 200 mg
     Dose: 1 tab qid
     How many tablets are needed for 24 hours?

  9. Metformin HCL 850 mg
     Dose: 1 tab BID PC
     How many tabs and when does the patient receive the doses?

  10. Methylprednisolone 40 mg/1 vial
      Dose: 40 mg q4 hrs
      How many vials are needed?

C. Answers

  Section 1                             Section 2
  1. 0.004                              1. 10 ml
  2. 2000                               2. 15 ml
  3. 4                                  3. 100 mg
  4. 0.01                               4. 4 mg/ml
  5. 20                                 5. 10 mg/ml
  6. 750                                6. 1 mg/ml
  7. 400                                7. 8 ml
  8. 0.6                                8. 4 tabs
  9. 0.003                              9. 2 tablets per day, 1 after each of 2 meals
  10. 30                                10. 6 vials




                                 19
F. Sample Test Questions

   On the following pages are sample test questions than may be used to assess competency
   with the T-C-T module. As with the module, the tests may be altered to fit site specific
   information. The questions should be changed periodically.


   1. History of the T-C-T Program


   To verify competency, the following questions must be answered correctly. Please
   complete the quiz and turn into to your hospital coordinator.

   1. True        or     False

      The Minnesota Board of Pharmacy established a law that stated a pharmacy
      technician could check patient unit dose carts.

   2. True        or     False

      The intent of the program is to free pharmacists from non-judgmental distributive
      functions so that their unique skills can be better utilized to improve the medication
      outcomes in hospitalized patients.

   3. Multiple choice

      What year did the Minnesota Board of Pharmacy require that there be an additional
      independent check of all medications prior to the administration to the patient?

      A.   1979
      B.   2002
      C.   1989
      D.   1991




                                           20
2. Requirements of the T-C-T Program

   To verify competency, the following questions must be answered correctly. Please
   complete the quiz and turn into to your hospital coordinator.

   1. Multiple choice

      To participate in the T-C-T program, a hospital must follow these guidelines:

      A.   The nurse must check the patient profile daily.
      B.   Floor stock medications can be checked by a technician checker
      C.   The hospital must receive a variance from the Board of Pharmacy.
      D.   A technician can be the hospital coordinator.

   2. True      or    False

      A part time technician can become a checker if they have one year’s equivalent
      experience in unit dose filling.

   3. Multiple choice

      All technicians must undergo the following training to participate:
      A.   Practical session
      B.   Didactic lecture
      C.   Validation
      D.   All of the above




                                      21
3. Elements of Checking

   To verify competency, the following questions must be answered correctly. Please
   complete the quiz and turn into to your hospital coordinator.

   1. True           or     False

      A medication that is to be used as a nebulized dose must be labeled with a “Not
      for Injection” sticker.

   2. True           or     False

      A formulary is a system managed by the P&T Committee that limits duplication
      of drug supplies in the hospital.

   3. Multiple choice

      IV medications that are not clear and colorless include the following:
      A.   Furosemide (Lasix) IV
      B.   Rifampin
      C.   Imipenem/Cilastatin (Primaxin)
      D.   B and C

   4. Match the product with the correct special handling or storage requirement.

      ________ Ipratropium (Atrovent)                      A. 24 hour stability


      ________ Famotidine (Pepcid) IV                      B. Needs refrigeration


      ________ Acyclovir (Zovirax)                         C. Send in an amber bag




                                      22
4. Accuracy and Medication Errors


   To verify competency, the following questions must be answered correctly. Please
   complete the quiz and turn into to your hospital coordinator.

   1. Name four types of errors that are commonly experienced at your site.

   2. Multiple choice

      All of the following are TRUE about the process of checking unite dose
      medications by a technician except:

      A. If filling errors are found, the technician checker may correct then without
         further checking by anyone
      B. The technician checker cannot check drawn up (extemporaneous) doses
         prepared by another technician.
      C. A pharmacist must check all unit dose medications that a technician checker
         reviews during the validation process.

   3. Match the abbreviation with the correct term:

      ______ pr                    A. oral                       F. left ear

      ______ au                    B. both ears                  G. milligrams

      ______ ng                    C. nasogastric tube           H. rectal

      ______ mcg                   D. micrograms                 I. nasojejunal tube

      ______ os                    E. left eye                   J. magnesium




                                      23
5. Validation and QA Process

   To verify competency, the following questions must be answered correctly. Please
   complete the quiz and turn into to your hospital coordinator.


   1. True    or      False

      Training for the T-C-T includes a validation process that requires a technician to
      check 3500 consecutive doses.


   2. True    or      False

      After initial validation, weekly audits are to be conducted at random.

   3. Multiple choice

      Which of the following are TRUE regarding the validation process?

      A. A pharmacist must check the accuracy of the technician checker during the
         validation process

      B. Documentation of the technician checking errors must be completed by the
         nurse and discussed.

      C. An error of the wrong drug (2 doses) in a unit dose cart is counted as 2
         checking errors.

      D. The technician filler artificially introduces at least 5 errors into an audit.

      E. A and C




                                        24
6. Answers to Test 1-5

   Test 1

   1. False
   2. True
   3. E

   Test 2

   1. C
   2. True
   3. D


   Test 3

   1.   True
   2.   True
   3.   D
   4.   C, B, A

   Test 4

   1. Wrong drug, wrong dose, wrong quantity, wrong dosage form
   2. A
   3. H, B, C, D, E


   Test 5

   1. False
   2. False
   3. A, C, E




                                    25
A. Sample Variance Request Letter*


Minnesota Board of Pharmacy
2829 University Ave SE, #530
Minneapolis, MN 55414-3251

Dear ________________:

I am requesting a variance to utilize the Tech-Check-Tech program in accordance with the
Minnesota Board of Pharmacy approved MSHP proposal.

The Tech-Check-Tech program will be conducted in accordance with the MSHP guidelines for
training, validation and quality assurance approved by the Minnesota Board of Pharmacy.

Please see attached copy of site specific required policies and procedures.


Thank you.


(Insert your name & site information)




* NOTE: A MN BOP Variance Request Form must be completed for the initial variance request
and for renewals. Data submitted with the initial request to initiate T-C-T should include the
policy and procedure for T-C-T, the policy and procedure around high risk medications and
evidence of the hospital committee approval of the program (e.g., meeting minutes). Renewals
should include the policy and procedure for T-C-T, the policy and procedure around high-risk
medications and QA audit documentation.




                                                26
B.      T-C-T Training Checklist

Name: ________________________                 Date: ________________

•    Qualifications: (check all that apply)

                A registered intern (in Pharmacy school) with six month’s experience in Unit
                Dose filling
                A technician working full or part time in Unit Dose filling with one year’s
                equivalent experience

•    Areas trained in as a Technician: (check all that apply)

                IV                                    First Fill
                UD                                    OR
                Pyxis                                 CartFill
                DSC                                   Billing

•    T-C-T Training

Didactic          completed: _______________ (enter date)

Process (1:1)     completed: _______________ (enter date)

Quizzes           completed: _______________ (enter date)

Validation         completed: _______________ (enter date)


T-C-T Training completed: ________________________




                                                 27
C. Initial Validation Form
To obtain T-C-T validation, a 99.8% accuracy rate must be achieved.

Unit of Use Batch: Must achieve required accuracy rate in 1500 consecutive doses (divided in at
least 5 separate audits). If candidate misses more than three errors they will fail the validation
process.

AMDS Batch: Must achieve required accuracy rate in 300 doses for unit of use and 100 line
items in an AMDS batch. If candidate misses more than one error they will fail the validation
process.



      DATE                  # DOSES               # ERRORS            % ACCURACY




                                                28
   D. T-C-T Audit Tool



            Date of Audit: ______________________


            T-C-T being audited: ______________________


            RPh conducting Audit: ______________________




Introduced Errors:
            Medication              QTY         Area        Description of Error
                                            (AMDS;Unit
                                             of Use;etc.)




Audit Results:

  # Doses     # Errors                Error Description       % Accuracy




                                              29
ASHP assumes no responsibility for documents posted by users of the ASHP shared members resources repository, or for any acts,
omissions or other conduct of its users. ASHP does not endorse or provide any representation or warranty with respect to any user or
posted document. Users are further referred to the Disclaimer and Limitation of Liability on the ASHP Web page, located at
http://www.ashp.org, the terms and conditions of which shall govern all uses of the shared member resources repository.

E. Tech-Check-Tech Monthly/Quarterly/Semiannual QA Tracking Form
(Each new T-C-T must complete 1500 consecutive doses in 5 separate audits of Unit of Use and 300 doses or 100 line items of AMDS
batches and obtain a 99.8% accuracy rate to become/remain validated)



Technician: ___________________________________

  Date      #Doses      #Errors       %Acc.        RPh         A           B           C           D           E           F




Error Types:
A = Too Few Doses
B = Too Many Doses
C = Wrong Drug
D = Wrong Dose
E = Wrong Dosage Form
F = Drug Expired
ASHP assumes no responsibility for documents posted by users of the ASHP shared members
resources repository, or for any acts, omissions or other conduct of its users. ASHP does not
endorse or provide any representation or warranty with respect to any user or posted
document. Users are further referred to the Disclaimer and Limitation of Liability on the
ASHP Web page, located at http://www.ashp.org, the terms and conditions of which shall
govern all uses of the shared member resources repository.

F. T-C-T Yearly Program Summary

                 1st Qtr.                                 2nd Qtr.

 2003            Date Doses Errors            % RPh Date          Doses Errors       %
Tech Name        X/X/X  #     #              #%




                3rd Qtr.                                  4th Qtr.
 2003            Date Doses Errors            % RPh Date          Doses Errors       %
Tech Name        X/X/X  #     #              #%
V.      References



     A. Tech-Check-Tech

        •   Grogan JE, Hanna JA, Haight RA.
            A study of Pharmacy Technicians working in a unit dose system. Hosp Phar.
            1978;13:194-9

        •   McGhan WF, Smith WE, Adams DW.
            A randomized trial comparing pharmacists to technicians as dispensers Med. Care.
            1983;21:445-53

        •   Piazza, C. Tech-Check-Tech. Unpublished master’s thesis. 1985. United Hospital, St.
            Paul, MN.

        •   Woller TW, Stuart J, Vrabel R, Senst B.
            Checking of unit dose cassettes by pharmacy technician. Am J Health-Syst Pharm.
            1991;48:1952-6

        •   Ness JE, Sullivan SD, Stergachis A
            Accuracy of technicians and pharmacists in identifying dispensing errors. Am J
            Health-Syst Pharm. 1994;51(3):354-7

        •   Spooner SH, Emerson PK. Using pharmacy technicians to check unit dose carts.
            Hosp Pharm. 1994;29:433-7

        •   Ambrose P, Saya FG, Lovett LT
            Evaluating the accuracy of technicians and pharmacists in checking unit dose
            medication cassettes. Am J Health-Syst Pharm. 2002;59:1183-8

     B. Safety References

            1. Institute for Safe Medication Practices (ISMP). http://www.ISMP.org

            2. Safest In America Initiatives

            3. JCAHO Standards

            4. Site-specific reported errors




                                               32

				
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